THE CAUSES AND PREVENTION OF ANASTOMOTIC LEAK AFTER
COLORECTAL SURGERY
BIELECKI K., GAJDA A.
DEPARTMENT OF GENERAL SURGERY, ORBOWSKI HOSPITAL, WARSAW, POLAND
The cause of the leakage may be multifactorial, including con­
tribution from faulty technique, ischemia of the intestine at the
suture line, excessive tension across anastomosis and mesente­
ry, the presence of local sepsis, presence of obstruction distal to
the anastomosis. The old patient (>80 years), anaemic, malnou­
rished with several coexisting diseases, receiving high doses ste­
roids, after chemio-radiotherapy is more prone to develop the
anastomotic leakage. The presence of any of these risk factors
calls into question the safety of the planned anastomosis.
Anastomotic leakage is the most significant complication after
colorectal surgery especially after anterior resection and it is
the major cause of postoperative mortality and morbidity. Defi­
nition of clinically apparent anastomotic leakage is following:
fistula to the skin or vagina, fever above 38°C or septicaemia
in patients with radiological or endoscopic leak, with presen­
ce of intraperitoneal abscess or symptoms and signs of perito­
nitis in the presence of an anastomotic leakage [1]. (Fig. 1)
Its frequency is higher after anterior resection. In 60% of cases lea­
kage heals under the conservative treatment. If re-laparotomy is
necessary the mortality related to this complication is very high.
The leak incidence varies from 3.4% to 40% (the larger figures inc­
lude subclinical radiological diagnoses) [5]. In the series published
after 1990 in the group of 1318 patients the rate of clinically detec­
ted anastomotic leak was 4.7%, varying between 2.7 and 10.5%.
In an addition 5.7%-10.7% of patients had subclinical leaks dis­
covered by routine postoperative radiological examination [2,3].
Goligher in 1970 found radiological leak in 69% of patients
with low colorectal anastomosis diagnosed by means of routi­
nely performed barium enema on 5-7-th day after surgery [4].
Our personal leak rate is 5.7% among 263 patients who under­
went colorectal resection and primary anastomosis.
The consequences of anastomotic leak are peritonitis, fistula
formation or abscess.
The principles of the good and reliable colorectal anastomo­
sis are as follows: (Fig. 2)
1. good exposure and access to large bowel (long enough inci­
sion)
2. adequate blood supply of anastomosed stumps
3. prevent sepsis or gross faecal contamination
4. sutures or staplers should be properly placed assuring good
approximation of all layers of bowel wall (most important
is submucosa)
5. no tension of the anastomosis (always release the splenic
flexure in left colorectal surgery)
6. prevent distal obstruction
7. the patient should be well nourished and large bowel should
be mechanically well prepared (no faecal contamination)
(Keighlyl993)[17].'
Good exposure includes: long incision, adequate bowel
mobilisation, appropriate illumination, correct positioning of
assistants and retractors.
Blood supply is essential for the healing of anastomosis. The
cut ends of bowel should bleed. To assess the adequate blood
supply of the bowel stump the routine measurement of tissue
oxygen and laser Doppler flowmetry are currently being evaKLINICKA ONKOLOGIE
ZVLÁŠTNÍ ČÍSLO 1999
25
Fig. 2
Fig.l
Definition of anastomotic leak
1. Faecal fistulas to the skin or vagina
2. Fever > 38 °C or septicaemia
3. Radiological or endoscopis signs of anastomotic leakage
4. Also an intraperitoneal abscess or peritonitis in the presence of
an anastomotic leak
Müller, 1994
luated in many centres. To achieve a good blood supply some
important operative precautions should be followed, namely:
adequate mobilisation, no tension on anastomosis, sutures
must not be placed too deep or too tight (extramucosal sutu­
res are the best in this aspect) used bowel clamps should be
non-crushing and should be lightly applied without including
the mesentery since that may compromise the blood supply.
Manual sutured anastomosis.
Since Czerny (1880) recommendation a two layer technique
of colorectal anastomosis was commonly used. The first lay­
er was an inner through-and-through suture which was either
continuous or interrupted and the second layer (usually inter­
rupted) was an outer serosomuscular Lambert stitch.
Halsted (1887) and Gambee (1951) showed that the submucosa was the strongest layer of the bowel wall and they sup­
ported the single layer technique with moderate inversion.
Currently generally accepted view is that for colorectal ana­
stomosis the inversion techniques should be employed.
Dunn and other authors stated that everted anastomosis should
not be performed in patients with abdominal infections, after
radiotherapy, with inflammatory bowel diseases [6]. These
are risk factors for anastomotic leakage especially after stap­
ling technique employed.
Kusunoki showed no significant differences in anastomotic
dehiscence (5-7%) or recurrence of Crohn's disease between
the stapling and hand-sewn procedures [7].
These results indicate that stapling technique producing an
everted anastomosis is a safe procedure for Crohn's disease.
Still exists controversy about the need for a one or two layer
anastomosis. Theoretically the two layer anastomosis produ­
ces more ischemia, the tissue necrosis and more narrowing of
the bowel lumen than one layer technique.
Currently for low colorectal extraperitoneal anastomosis one
layer manual anastomosis is recommended. A two layer ana­
stomosis is performed in more proximal colon whenever it is
reasonable to do so. In many centres most surgeons opt to use
the circular staplers.
To perform a two layer anastomosis the absorbable material is used
for inner layer and non-absorbable material for an outer layer.
A single layer anastomosis is accomplished using a non-absor­
bable material usually monofilament, which causes less tis­
sue reaction. N e w developed long-resorbable materials, like
vicryl, P D S , maxon, are recommended for one layer colorec­
tal anastomosis. The size or gauge of the suture material is
usually 00 or 000 for adult intestinal anastomosis and the need­
le is of the round type.
There are numerous variations in technique to perform ana­
stomosis. Most common are: end-to-end anastomosis (doub­
le layer, single layer full thickness, single layer extramucosal)
end-to-side anastomosis, side-to-side anastomosis.
End-to-side anastomosis many surgeons prefer to perform fol­
lowing right hemicolectomy or after low rectal anterior resec­
tion. Most essential is to secure the mesenteric and antimesenteric corners by using the Connell stitches. Personally, I prefer
to anastomose short distal rectal stump to side of proximal colon
employing end-to-side technique (so called Baker technique).
26
KLINICKÁ ONKOLOGIE
ZVLÁŠTNÍ ČÍSLO 1999
The Principles Of Large Bowel Anastomosis
1. Good access and exposure
2. Adequate the blood supply of two ends of bowel (no clamps)
3. Sutures or staples should be properly and meticulously placed
(layers appprocimation, the role of the submucosa)
4. No tension on the anastomosis (relase of the splenic flexure)
5. No faecal contamination (ideally empty the large bowel)
6. Prevent distal obstruction
7. The patient should be well nourished
An alternative to manual techniques is the use of staplers. Stap­
lers have allowed colonic or rectal closure and anastomosis is
performed more quickly than manually.
There are three types of stapling instrument which are appli­
ed in colorectal surgery. These are linear staplers ( T A or R L ) ,
the linear cutters ( G I A or P L C ) and the circular instrument
( E E A or l L S ) .
Whether stapled anastomosis is more tight and reliable than
conventional hand-sewn is open to debate. Reported leak rates
after stapled and hand-sewn anastomosis were 8% and 27%
respectively.
Thirteen randomised, controlled trials showed a little or no dif­
ferences between hand-sewn vs. stapled anastomoses in outco­
me variables including mortality, technical problems, leak rates,
wound infections, strictures and cancer recurrences [8].
Strictures and intraoperative technical problems were more
common with stapled than hand-sewn anastomosis. Thus both
techniques are effective, stapled technique is a little bit quic­
ker but the choice may be based on the personal preference.
Hashemi showed, that side-to-side stapled anastomosis is asso­
ciated with lower incidence of recurrence in Crohn's disease
requiring reoperation (2%) at 46 months with comparison to
the end-to-end hand-sewn anastomosis (43%) [28].
However longer follow-up is required to evaluate this techni­
que in randomised prospective study.
Docherty and co-workers in randomised, controlled trial eva­
luated 732 patients who had had any form of elective or emer­
gency colorectal resection or reconstruction. In patients having
suturing or stapling of anastomoses was equally effective. In
patients who had colorectal anastomoses, incidence of radio­
logical leak were lower when staplers were used [29].
Factors influencing anastomotic healing.
The morbidity and mortality related to anastomotic breakdown
in colorectum is considerable. Fielding (1980) in his study
showed, that among 1466 patients who underwent large bowel
anastomosis there were 191 patients with an anastomotic leak
with 22% of hospital mortality compared with 7.1% of 1275
patients without a leak [9].
Anastomotic leak can only be prevented if the causes are
understood. Many factors may play a pathological causative
role, including: (Fig. 3)
1. poor surgical technique
2. wrong intraoperative judgement
3. local complications (sepsis, bowel preparation, drains, role
of omentum and peritoneum, anaesthetic drugs, protective
stoma)
4. systemic complications (nutritional status, blood loss)
5. surgeon-related factors, which are of the most important
causes of an anastomotic leakage.
Local sepsis
The presence of local sepsis (e.g. perforated diverticulitis,
a perforated colorectal cancer, colorectal trauma, faecal con­
tamination during colorectal surgery) causes the reduction in
collagen at the colonic anastomosis. This may result in hig­
her anastomotic dehiscence rate.
Fig. 3
Fig. 4
i
Factors Affecting Anastomotic Healing
1. Poor surgical technique
2. Wrong or lack of intraoperative judgement
3. Local complications (sepsis, bowel preparation, drains, role
of peritoneum and omentum, drugs used during anaesthesia)
4. Systemic factors (nutritionale state, bloods loss)
5. Surgeon-related factors, which are of the most important causes
of an anastomotic leak
Bowel preparation
Most surgeons use mechanical bowel preparation before colo­
rectal surgery as essential in preventing complications. It is
generally accepted that faecal loading has an adverse effect
on the healing of large bowel anastomosis. A meta-analysis
conducted by Platted showed that there is a limited evidence
in literature to support the use of mechanical bowel prepara­
tion in patients undergoing colorectal surgery [10]. (Fig. 4)
Three clinical trials showed a significant greater incidence of
wound infection and anastomotic leak in patients who recei­
ved a mechanical bowel preparation (10.8% and 8.1% res­
pectively) comparing with patients without preparation (7.1%
and 4% respectively) (fig 1). Remembering mentioned above
there is a little doubt that is safer to leak from an empty bowel
than from one that is loaded with faeces. (Fig. 5)
Recently again Miettinen and co-workers demonstrated, that
preoperative bowel preparation seems to offer no benefit in
elective open colorectal surgery in regard of mortality, wound
infections and anastomotic leakage rate [11].
The Principles Of Large Bowel Anastomosis
anastomotic leak
wound infection
(+)
8.1%
1.0.8%
(-)
4%
7.4%
Plattel, Dis. C Red. 1998, 41, 875
Protective stoma
Some surgeons advised to create a defunctioning stoma in
order to prevent faecal contamination of an anastomosis and
when anastomotic leak appears.
The decision whether to create a protective colostomy or ileo­
stomy is often not a matter of objective reason but one of emo­
tion like feeling that operation was technically difficult to per­
form, there was considerable blood loss, the tumour was stuck
in the pelvis, the patient had many medical problems, the ana­
stomosis looked tenuous, there was some tension across the
anastomosis, I didn't feel good about it, I ' l l sleep better tonight.
A l l those are reasons for protecting the anastomosis with a pro­
ximal stoma.
Probably the most common reason for a subsequent anastomotic
complications is tension in suture line (distraction, vascular insuf­
ficiency). If the above precautions are taken a protective colosto­
my is usually unnecessary. There are relative indications for pro­
tecting the anastomosis which are following: pelvic sepsis, exces­
sive blood loss and arterial hypotension, poor nutritional status
and ultralow anastomosis (below 6 cm from the anal verge).
It is generally believed that a temporary defunctioning colo­
stomy is avoided more often if a stapled anastomosis is per­
formed than if a hand-sewn technique is used.
However recent experimental evidence in rats demonstrates,
that a proximal diverting colostomy may reduce of collagen
metabolism, anastomotic protein level and delay of the deve­
lopment of anastomotic strength [12,13,14].
There is no evidence that protective stoma prevents the ana­
stomotic leak. On the other hand all surgeons know, that if
leak does take a place in patient with diverting stoma, the sep­
tic complications resulting from the anastomotic dehiscence
are significantly reduced.
Wessex (Grabham) colorectal audit showed, that a defuncti­
oning colostomy reduced the frequency of anastomotic leak
from 11.4% to 6.5% [15]. Reoperation was needed more fre­
quently where there was no protective stoma (7.3% vs. 3.0%).
Postoperative mortality was greater following a leak, where
no diversion was performed (10.4% vs. 4.1%). (Fig. 6)
Presented data showed, that diverting colostomy decreases
both the frequency and consequences of anastomotic leakage
following anterior resection. More experienced surgeons use
more frequently defunctioning colostomy performing low rec­
tal anastomosis.
Tube caecostomy as a mean of protecting the low rectal ana­
stomosis is advocated to facilitate postoperative management
and to avoid the need for defunctioning stoma requiring for­
mal closure having own morbidity and mortality [16].
However, intraluminar intracolonic bypass technique using
coloshield or condom is a very safe, cost-effective and easily
available alternative for coloanal anastomosis [19,20].
Hirsch et al. stated, that removing completely blood, serum,
cellular debris from pelvis following resection of rectum and
mesorectum minimises the risk of anastomotic breakdown.
They believe that with this, routine defunctioning colostomy
is no longer required for most patients undergoing low ante­
rior resection with total mesorectal incision [26].
Drains which are situated in direct and close distance from
anastomosis may contribute to anastomotic leakage and sepsis
[17,18]. This must be considered when surgeon decides to dra­
in abdominal cavity. Abdomino-perineal resection is the only
colorectal procedure for routine drainage.
It is difficult to assess the role of peritoneum and of the omentum
in prevention of anastomotic breakdown. There is no controlled
trial in man, which support the technique of wrapping an anasto­
mosis with omentum or peritoneum as the prevention of leak.
However several surgeons do this manoeuvre whenever [17].
Fig. 5
Fig. 6
Colorectal surgery
wound infection death
only mechanical
preparation
36%
11.2%
mechanical preparation
with antibiotic prophylaxis
22%
4.5%
1996 - Wessex Colorectal Audit: Anastomotic
Leak After L A R
diverting colostomy no diverting colostomy
frequency of the leak 6,5% (p=0.043)
11.4%
need of reoperation 3.0% (p=0.0024)
7.3%
postoperative mortality
4.1%(p<0.05)
10.00%
more experienced surgeon
leak<6.9%, proximal
(>
10
operations/year)
colostomy in 49.6%
less experienced surgeon
leak >14.1%, proximal
(<10 operations/year)
colostomy in 30 %
KLINICKÁ ONKOLOGIE - ZVLÁŠTNÍ ČÍSLO 1999
27
Fig. 8
Fig. 7
-
Intraoperative Air Text To Asses
The Anastomotic Tihgtness
Test performed - in 23% of cases air leak, additional
sutures, on 10th day after operation the radiological leak
in 7.5% of cases, mortality 2%
Test not performed - on 10th day postoperatively the
radiological leak in 23.5% with mortality 10%
We are concerned about the integrity of an anastomosis, about
anastomotic blood supply, particularly in elderly patients and the­
se with severe atherosclerosis or cardio-respiratory insufficiency.
It is important from the practical point of view to assess the
anastomotic integrity by using intraoperative air test (cycle
tire puncture manoeuvre).
Once anastomosis is performed the pelvic cavity is filled with
saline, intestinal clamp is applied proximal to the anastomosis
and 50-100 ml of air is slowly and gently injected through the
anus. No bubbles means anastomotic tightness. In case when
bubbles appear an additional suture on the anastomotic line is
required [12]. In the group of patients to whom intraoperative
air test was performed in 23% of cases air leak was observed.
This was an indication for additional stitches to secure anasto­
mosis. On 10-th postoperative day the radiological leak in 7.5%
of cases was showed and overall mortality in this group was 2%.
In the contrast, in group of patients to whom intraoperative air
test was not performed, postoperative radiological leak was
found in 23.5% of cases with 10% mortality [12]. (Fig. 7)
Risk factors for development of
an anastomotic leak (1726 pts)
1. L A R vs. other procedures (leak 4.4% vs. 1.4%, p<0.001)
2. Pre-existing sepsis vs. no-sepsis (5.0% vs. 1.5%,p<0.005)
3. Heavy intraoperative faecal contamination vs. minimal
contamination (11.3% vs. 23%,p<0.001)
4. Perianastomotic drains vs. no drain (6.3% vs. 1.9%, p<0.001)
5. Proximal diverting stoma vs. no stoma (9.8% vs. 1.9%,p<0.001)
6. Emergency vs. elective surgery (4.1% vs. 1.9%, p - ns)
epithelium). Hananel and Gordon in their experimental study
demonstrated the 5-fluorouracil and leucovorin introduced in
several regimens have no effect on the colonic anastomosis hea­
ling process [23]. Surgery, at least in experimental animals, can
be performed safely during and shortly after chemotherapy.
Systemic factors
The role of systemic factors in aetiology of anastomotic leak
is not yet completely defined. Among systemic factors at least
three of them do seem to play a significant role and they are:
1. malnutrition (serum albumin level below 3.0 g/dl)
2. anaemia - Hb below 1 l g % and hematocrit below 33%
3. excessive blood loss and advanced malignancy.
Excessive blood loss results in reduction of colonic blood flow
with subsequent tissue necrosis. B l o o d loss inevitably leads
to the need of transfusion, which in turn has been shown to
decrease the patientis immunocompetence.
Anaesthetic drugs
Neostigmine which reverses the effect of the curare-type relaxants
might evoke active contraction of the intestine after completion of
the anastomosis and subsequently might result in its disruption.
Current evidence suggests, that neostigmine should be avoided
during colorectal surgery even with combination with atropine.
Halothane anaesthesia, however, abolished this neostigmine
adverse effect [17].
It is widely accepted that corticosteroids have a deleterious
effect on healing of skin wounds. Little is known about effect
of steroids on the healing of colonic anastomosis.
Schrock et al. (1973) found that administration of corticoste­
roids did not increase significantly incidence of clinical ana­
stomosis leakage (retrospective study) [21].
From experimental study Furst et al. reported that steroids do
have an adverse effect on colonic anastomotic healing [22]. It
requires further clinical as well as experimental investigations.
Antineoplasmatic drugs can potentially adversely affect the hea­
ling process of large bowel anastomosis via several mechanisms
like impairment of the synthesis and maturation of collagen,
retardation of production and function of the cellular mediators
of the healing process (macrophages, fibroblasts, leukocytes,
Other risk factors
Averbach et co-workers published very interesting results of an
analysis of risk factors for anastomotic leak after double-stapled
low colorectal resection. The incidence of anastomotic leak was
directly related to extent of proximal colon resection [24].
Standard colon resection for sigmoid colon-to-rectum anastomosis
was associated with 1 % leak rate compared with 29% leak after trans­
verse colon-to rectum anastomosis. Averbach presents also a risk fac­
tors list of anastomotic leak after low anterior resection [Table 1].
The most important factor for prevention of anastomosis brea­
kdown is a good surgical technique that can improve with expe­
rience. The mobilisation of splenic flexure (with high ligation
of the inferior mesenteric vein) is essential to decrease the ten­
sion across the anastomotic line and subsequently to prevent ana­
stomotic dehiscence. In case of the narrow pelvis of small male
patients or in patients with a bulky tumour a triple stapling tech­
nique (TST) is advocated in which a proximate linear stapler is
used twice for transverse occlusion of the rectum. Staplers are
fired from both sides of the rectum. The centre of the rectum
with crossed staples is removed by a further procedure that is as
the same as the standard double stapling technique [25].
Anterior resection for rectal cancer is associated with higher
incidence of anastomotic leak. Total mesorectal excision ( T M E )
reduced the incidence of local recurrence of the tumour but inc-
Fig. 9 Treatment of patients with anastomotic leak
Fig. 10
L A R - functional outcome
median anastomotic height above anal verge -6 cm
„neorectal" volume at distention,
pressure of 40 and 50 cm H 2 0
compliance at sensation of filling
urge to defecate
maximum tolerated volume
28
KLINICKÁ ONKOLOGIE
ZVLÁŠTNÍ ČÍSLO 1999
present
reduced
absent
114 ml
reduced ~ 4 ml/cm H 2 0
reduced ~3.5 ml/cm H 2 0
reduced ~3ml/cm H 2 0
Fig. l 1
Fig. l 2
Multifactorial Index Risk Factors in Colon Resection
(Ondrula et al.. Dis. Col. Rect. 1992)
1
reased the rate of anastomotic dehiscence. Karanjia reported
11%of major anastomotic leaks associated with peritonitis and
6.4%of asymptomatic leaks detected by contrast enema.
All major leaks occurred at an anastomosis situated below
6 cm from anal verge. Defunctioning stoma reduces the incidence of major leak and protects against the development of
peritonitis. It has been considered it prudent to defunction the
low rectal anastomosis below 6 cm from anal verge, particularly after total mesorectal excision [27].
With meticulous attention to the technical issues described
below anastomotic complications can be kept to less than 5%
of the bowel resections.
Technique
a) Conventional suturing- suture ,,~nterruptedor continuous,
should take deeper muscularis and minimal mucosa, good
approximation all layers of bowel wall; the floor of the pelvis is not reconstituted but is vigorously imgated with saline; no drains are advised
b) Stapled anastomosis- various stapling technique can permit
a secure anastomosis. Following principles are essential for
minimising complications related to the use of staplers:
I. Use the largest calibre of stapler the anastomosis can
accommodate
11. After placing of the purse-string the excessivebulk of
tissue should not appear around shaft
111. The purse-string can be snagged up close to the shaft
IV. Reinforce the purse-string if one is concerned about
the possibility of a gap
V. Repair any identified defect
VI. on-satisfactory anastomosis(e.g. incomplete doughnuts) mandates a diverting colostomy or evidence of
primary anastomosis.
Most common factors leading to anastomotic leak are: disease of the bowel itself, inadequate blood supply and diseases
that affect local blood flow particularly in distal stump, tension on the suture line, inaccurate suture placement, trauma and
failure to obtain a watertight seal.
The implementation of intraoperativeair testing or direct visualisation of anastomosis by means of the sigmoidoscopecan
reduce the leak rates from 14%("no test" group) to 4%("test"
group).
The presence of drains is associated with an increased incidence of anastomotic leakage. Drains may adversely affect an
anastomotic healing. Selectively used protective colostomy
does not prevent the developmentof anastomoticleak but when
it happens colostomy reduces the mortality and morbidity.
Low anterior resection, pre-existing sepsis (beforeoperation),
heavy faecal contamination during operation, perianastomotic drainage, proximal diverting stoma, emergency operation,
cardio-respiratory insufficiency and less experienced surgeon: these are most essential risk factors for the incidence of
an anastomotic leak. (Fig. 8)
The prompt diagnosis of anastomosis leak has a paramount
value for the patient. Contrast enema with either uropolin or
gastrographine enables early diagnosis of anastomotic leak.
'
1
ColovxhI Anaatmwls
'
Determinationof lysozymecontent in the wound or in the effluent from pelvic drains might be useful in early diagnosis of
anastomotic dehiscence.
Lysozyme is a component of local defence and is produced in
macrophages. In patients with impending anastomotic leak,
lysozyme activity is significantlyincreased as early as the first
postoperative day in contrast to patients without any anastomotic complications [30].
Total parental nutrition,broad spectrum antibiotics, treatment
of the septic shock and prompt surgery (depends on patient
status and diameter of fistula) are essential for the patient.
Disconnection of breakdown anastomosis followed by Hartman procedure is a treatment of the choice in anastomotic
dehiscence bigger than 1 cm. (Fig. 9)
Long-termfunctional outcome after LAR may be impaired by
anastomotic leakage [31]. In patients with leak as the results
of pelvic sepsis, the fibrosis may develop with subsequent narrowing of the distal bowel or stricture formation. (Fig. 10)
"Neorectal" volume at distension pressures of 40 and 50 cm
H20 and compliance at sensation of filling urgency maximum
tolerated volume were significantlyreduced in patients with anastomotic leak. The impaired anorectal function is measured by:
1. increased frequency of bowel movements
2. increased urgency
3. increased incontinence score and
4. impaired evacuation.
In addition anastomotic leak may increase the risk of locoregional neoplastic recurrence [32].
Summary
Several systemicand local factors play significantrole in aetiology of anastomotic leak.
Systemicfactors are: shock, sepsis, advancedage of patient (above 75 y.), coagulopathy, steroids, advanced malignant disease,
Table 1
Risk Factors of Anastomotic Leak after Low Anterior Resection of
the Rectum (Surgical Treatment Only)
~emonstratedin randomised trials
Low (below pentonea reflexion) vs. high anastomosis
implicated
inadequate blood supply; tension on suture line
Septic conditions or undrained pelvic collection
Preoperative radiotherapy, chemotherapy, steroid therapy
Patients condition (concurrent disease), age
Inadequate bowel cleaning or emergency or palliative surgery
Shock during surgery, coagulopathy
Vitamin C, iron, zinc, methionine and cysteine deficiency (unbalanced
collagen lysislsynthesis)
Implicated especially to double-stapledtechnique
Mucosal tears caused by anvil or staple gun insertion
Excessive upward traction of rectal stump during insertion or closing of
an instrument
Forceful extraction of an instrument
Failwe of staples closure
Adapted from A.M. Averbach et al. Dis. Colon Rectum 1996,39,780
KLINICKA ONKOLOGIE - ZVLASTNI CfSLO 1999
29
radio- and chemo-therapy, diabetes, uraemia, anaemia, iron, zinc,
cystein, vitamin C depletion, malnutrition with hypoalbuminemia, congestive heart failure and chronic obstructive pulmonary
disease. (Fig. 11)
Local factors are: intraabdominal sepsis, bowel preparati­
on, defunctioning stoma, peritoneum, omentum, drains, ana­
esthetic drugs. It seems to me that local factors and parti­
cularly surgeon-related variables are far more important.
F i e l d i n g in 1980 clearly showed, that the leak rates amongst
84 surgeons in 23 hospitals who performed 1466 colorectal
anastomoses varied from 0.5% to 30% [9]. This means that
some surgeons perform anastomosis badly. It might be rela­
ted to individual surgical technique, lack of judgement and
l o w case-load.
Having some risk factors, which might impair the healing pro­
cess of performed anastomosis I recommend the following
procedures:
References:
1. Muller F. P., Schmidt W.U., Hesterberg R., Roher H. D. 'Treatment of
anastomotic leakage after colon and rectum resection", Br. J. Surg, 1994,
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2. Moritz E., Achleitner D., Holbling N. Et al. "Single vs. Double stapling
technique in colorectal surgery: a prospective, randomized trial", Dis. Colon
Rectum 1991,34,495-7
3. Bokey E. L., Chapins P. H., Fung C et al. "Postoperative morbidity and
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4. Goligher J. C, Giahem N. G., De Dombal F. T. Et al.: "Anastomotic dehiscence
after anterior resection of rectum and sigmoid", Br. J. Surg. 1970,57,109-118
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8. MacRae Helen M . , McLeod Robin S. "Hand-sewn vs. stapled anastomo­
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stomotic integrity after operations for large bowel cancer: a multicentre
study", Br. Med. J., 1980,282,411-4
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30
KLINICKÁ ONKOLOGII
ZVLÁŠTNÍ ČÍSLO :
1. to avoid primary anastomosis and two-stages operation
(Hartman or Hartman-like operation) should be performed
2. one-stage colorectal resection with primary anastomosis
with anastomosis protection using intracolonic bypass
tubes like biodegradable tubes, coloshield, condom (WanHee, Ger, Ravo) [19,20].
3. Intraoperative air test for the assessment of tightness of the
anastomosis
4. the proximal ileostomy or colostomy routinely performed
in ultra-low coloanal or colorectal anastomosis particular­
ly in patients presenting risk factors
M i n i m a l local tissue necrosis, minimal collagenase activity,
minimal "foreign body" reaction and ideal apposition of all
layers of bowel wall of both anastomosed stumps (particular­
ly submucosa) warrant that minimal risk of anastomotic dehis­
cence w i l l take place. (Fig. 12)
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